Excision of Lesions. Brenda Chidester-Palmer CPC, CPC-I, CEMC, CASCC, CCS-P. All Rights Reserved. Objectives

Transcription

1 Excision of Lesions Surgical Approach Brenda Chidester-Palmer CPC, CPC-I, CEMC, CASCC, CCS-P 1 Objectives In this session we will discuss Lesion categories Removal versus biopsy Different lesion removal techniques Approach for excision of lesions Correct Diagnosis Coding 2 1

2 Lesion Categories Skin tag Wart plantar, common, viral Lesion benign, malignant, uncertain Mass or Lump Cyst Tumor 3 Coding Choices We base our code selection on a number of factors Removal or biopsy Type of lesion Benign or Malignant Cyst or Tumor Location of lesion Size 4 2

3 What are we actually doing? Biopsy we are only taking a piece or sample of the lesion or growth to have pathology tell us what the lesion is. Removal we are removing the lesion in toto. This does not mean we will not send out for pathology. 5 CPT codes are for biopsy procedures. Punch Biopsy 6 3

4 Shave Biopsy This can be confusing terminology when coding. A physician i may document they performed a shave biopsy but there is not a corresponding CPT with this exact verbiage. Our choices are the biopsy codes the shave excision codes 7 Shave Biopsy, cont. To correctly code for these services, we must make sure we understand d what the physician meant by shave biopsy. Some are actually doing the shave excision and some just a biopsy. Careful review of the documentation and/or query or the physician is necessary for correct coding. 8 4

5 Biopsy Other Codes There are other biopsy codes throughout the surgery subsections but, these are not for biopsy of lesions: Biopsy of muscle, superficial Biopsy of muscle, deep Biopsy of lip Biopsy of vestibule of mouth Renal biopsy, percutaneous 9 Different Lesion Removal Techniques There can be several definitions to the term remove that physicians use for cysts, masses, lesions, or neoplasm. 10 5

6 Ligature Strangulation Used on skin tags Physician uses suture material. Loops the suture material into a circle, places the circle over the pedicle, pulls tight and yanks off. 11 Ligature Strangulation, cont. Correct CPT codes for this type of removal are the and This is not the only type of removal for this code set. These codes are specific to skin tag removal and are for any method including chemical destruction, electrosurgical destruction, or any combination of methods. 12 6

7 Paring or Cutting This technique is used for benign hyperkeratotic skin lesions such as corns or calluses. CPT codes are For paring a curette, blade or similar sharp instrument is used. 13 Shave Excision Shaving is not a full thickness dermal removal. It involves a transverse incision or horizontal slicing. Removes lesion just to level of skin. 14 7

8 Shave Excision Code selection is based on anatomic location and size Size range is: < 0.5 cm to 2.0 cm or > Trunk, arms, or legs Scalp, neck, hands, feet, genitalia Face, eyelids, nose, lips, mucous membranes 15 Destruction of lesions Destruction can be performed via: Cyrosurgery Chemosurgery Electrosurgery Laser surgery Surgical curettage 16 8

9 Curettage Removal with a curette of a planters wart on the sole of the foot 17 Chemical Destruction Chemicals are applied directly to a lesion to destroy. They are applied with a brush or cotton swab or injected into the lesion. Typically chemicals used are: Liquid nitrogen (LN2) Trichloracetic acid Cantharidin (on warts) Salicylic acid 18 9

10 Chemical Destruction, cont. Used for the following: Skin tags Warts Benign lesions Malignant lesions 19 Cryosurgery Destruction Examples of how chemicals can be applied This application freezes the lesion

11 Electrosurgical Destruction When we use the term electrosurgical, we are using a general term that encompasses the different procedures used to employ electrically generated heat. 21 Electrosurgical Destruction Tissue destruction by electro-surgery is the result of the following factors: Ohmic Heat Convective Heat Mechanical Energy 22 11

12 Electrosurgical Destruction Electrofulguration Does not touch lesion Distance of 2-3 mm Short bursts (2-3 sec) Electrodessication Lesion touched with electrode Bursts are longer (2-4 sec) Current intensity slightly increased 23 Electrosurgical Destruction Electrocoagulation Deeper tissue destruction Lesion may not be touched High current Deep necrosis Electrosection Cuts tissue Solid state current Simultaneous hemostasis Delayed healing 24 12

13 Laser Surgery Lasers can be used to destroy lesions or warts. Laser beam is directed at lesion. Not the preferred method of removal. 25 Destruction Codes Coding for destruction of lesions is not based on the method of destruction ti (chemosurgery versus surgical curettage). It is based on the TYPE of lesion we are destroying and how MANY we are destroying and LOCATION of the lesion(s)

14 Destruction Codes Under the subheading of Destruction there are 2 categories Destruction, Benign or Premalignant Lesions Destruction, Malignant Lesions, Any 27 Destruction Codes Benign/Other pre-malignant lesions (AK s) cutaneous vascular proliferative lesions benign lesions other than skin tags or cutaneous vascular a lesions s chemical destruction granulated tissue 28 14

15 Destruction Codes Malignant Trunk, arms or legs Scalp, neck hands, feet, genitalia Face, ears, eyelids, nose lips, mucos membrane 29 Destruction Codes Destruction codes can be found in other Surgery Sections besides the Integumentary subsection. These codes are specific for lesions in certain anatomical sites. If there is not a code in a specific section, the codes from the integumentary section would be used

16 Destruction Codes Other Examples of these codes: Excision or destruction intranasal lesion Destruction of lesion or scar of vestibule of mouth by physical methods (eg, laser, thermal, cryo, chemical) Destruction ti of rectal tumor (eg, electrodesiccation, electrosurgery, laser ablation, laser resection, cyrosurgery) transanal approach 31 Destruction Codes Penile Lesion First we have SIMPLE destruction that is further divided by METHOD of destruction: Destruction of lesions, simple; CHEMICAL Destruction of lesions, simple; ELECTRODESICCATION Destruction of lesions, simple; CYROSURGERY Destruction of lesions, simple; LASER SURGERY 32 16

17 Destruction Codes Penile Lesion Next we have EXTENSIVE destruction and is if for ANY method: Destruction of lesions, extensive; (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery) 33 Destruction Codes Vulva/Vagina Destructions of lesions of the vulva and/or vagina are divided by SIMPLE and EXTENSIVE like the penile lesion destruction, however, they are not further divided by method Destruction of lesion(s), vulva; simple Destruction of lesion(s), vulva; extensive Destruction of lesion(s), vagina; simple Destruction of lesion(s), vagina; extensive 34 17

18 Chemotherapy Destruction Codes These codes are in the Medicine Section They describe injecting a chemotheraphy agent (like 5FU) directly in to the lesion(s). Codes are further categorized by how many lesions: Chemotherapy administration; intralesional, up to and including 7 lesions intralesional, more than 7 lesions 35 Excision Excision of lesions: Performed with several different types of incisions Performed on: Skin lesions Subfascial masses Intramuscular masses Soft tissue 36 18

19 Surgical Excision This technique requires an incision. There are several types of incisions you may see documented in the procedure or operative note: Longitudinal Elliptical l Transverse Cutting (or curettage) 37 Surgical Excision Longitudinal incision Parallel to the long axis of the body or any of its parts Used for cyst or masses under the skin Documentation can read Longitudinal incision made overlying the cyst 38 19

20 Surgical Excision Transverse incision At right angles to the long axis of the body Cross-wise Horizontal Used for excision of lesions or masses primarily under the skin 39 Surgical Excision Elliptical incision Circular Oval Around the lesion Over the mass 40 20

21 Surgical Excision To determine the correct lesion codes for excision i we must know several things: Approach Size of the lesion For skin lesions we must also know: Malignant Benign Margins 41 Surgical Excision Under the subheading Skin, Subcutaneous, and Accessory Structures we have two categories for excision Excision Benign Lesions Excision Malignant Lesions 42 21

22 Surgical Excision - Benign Trunk, arms, or legs Scalp, neck, hands, feet, genitalia Face, ears, eyelids, nose, lips, mucous membrane 43 Surgical Excision - Malignant Trunk, arms, or legs Scalp, neck, hands, feet, genitalia Face, ears, eyelids, nose, lips 44 22

23 Excision Lesions Margins Another factor in choosing the correct code for skin lesion removal is the area or margin around the lesion that was also excised. We do add this area to our lesion size and select the code based on the total sum of the margin and the lesion. 45 Excision Lesions Margins When removing a lesion that pathology shows BCC (basal cell carcinoma) with involvement of skin and surround tissue, we want to make sure we select the code based on the lesion size AND how much skin area was also taken

24 Excision Lesions Margins Case example 2.4 cm lesion, upper right arm, involvement of surrounding skin/tissue. We are excising along with a 1.5 cm surrounding margin. 47 Excision Lesions Margins 2.4 cm lesion 1.5 cm margin 3.9 cm excision of malignant lesion =

25 Surgical Excision If we are making a incision to remove masses or tumors in the subcutaneous tissue or below. We have other codes to select from. Depending on the type of lesion/mass and where it is located, we code from a different subsection entirely. 49 Musculoskeletal Excision Codes- examples Codes for removal of soft tissue tumors Subcutaneous of face or scalp Sub-fascial face or scalp Radical (malignant) face or scalp 50 25

26 Respiratory Excision Codes- examples There are also codes in the respiratory section Dermoid cyst, nose; simple, skin, subcutaneous Dermoid cyst, nose; complex, under bone or cartilage 51 Digestive Excision Code Examples Excision of lesion of mucosa and submucosa, vestibule of mouth; without t repair with simple repair with complex repair 52 26

27 Digestive Excision Code Examples Excision of lesion of tongue without closure Excision of lesion of tongue with closure; anterior two-thirds Excision of lesion of tongue with closure, posterior one-third Excision of lesion of tongue with closure, with local tongue flap 53 Digestive Excision Code Examples Excision or destruction of lesion of pharynx, any method 54 27

28 Urinary Excision Code Examples Ablation, open, 1 or more renal mass lesion(s), cryosurgical, including intraoperative ultrasound guidance and monitoring, if performed Ablation, 1 or more renal tumor(s), percutaneous, unilateral, radiofrequency Ablation, renal tumor(s), unilateral, percutaneous, cryotherapy 55 Excision Codes Codes can be found in all sections of CPT not just the ones mentioned. We select code based on the operative note

29 Diagnosis Coding We need to make sure our diagnosis codes support our choice of CPT code. We should not bill for an excision of a cyst with a code for malignant lesion or wart. 57 Diagnosis Coding Benign Lesions Carcinoma in situ Neoplasm of uncertain behavior Neoplasm of unspecifed nature

30 Diagnosis Coding Malignant neoplasm Secondary malignant neoplasm Skin Tag AK Diagnosis Coding Warts Common Venereal Genital Plantar Seborrheic Inflamed Seborrheic Flat

31 Diagnosis Coding Condyloma Acuminatum Venereal Corns/calluses Diagnosis Coding There are numerous other codes that accurately describe lesions or growths after they are confirmed by pathology

32 Questions??? Thank You com 63 32